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Managing Pneumonitis in NSCLC

Panelists: Leora Horn, MD, MSc, FRCPC, Vanderbilt University Medical Center; Edward B. Garon, MD, David Geffen School of Medicine at UCLA; Thomas E. Stinchcombe, MD, Duke Cancer Institute
Published: Tuesday, Oct 16, 2018



Transcript: 

Leora Horn, MD, MSc, FRCPC: You brought up radiation pneumonitis. Radiation pneumonitis was low in that study. That was a nice surprise. Overall, pneumonitis was low in the study. We did not see a higher incidence. How are you sorting all of this out in patients who have pneumonitis? What is the culprit? Was it you, or was it your radiation oncology friend? How are you managing these patients? What are you doing?

Thomas E. Stinchcombe, MD: Something very important about the study is that the patients were enrolled after chemoradiation. I think the people who had significant toxicity were probably never enrolled on the PACIFIC trial. In the clinic, we see those people and we have to manage them. Generally, for people who we start on durvalumab and then they get pneumonitis, it can be very tricky to determine whether it’s the radiation or the durvalumab. This can be problematic. I did put 1 person on steroids. It turned out that she had pneumocystis pneumonia. And so, I think we have to be very vigilant and not just assume that it’s pneumonitis in this situation. These are new waters for us to tread in.

Leora Horn, MD, MSc, FRCPC: The patient probably didn’t get better on steroids, so that is something to think about it. But whether it’s immune radiation pneumonitis, they both respond to steroids. If they don’t get better, get your pulmonologist involved right away?

Thomas E. Stinchcombe, MD: I think an integrated system where the pulmonologist knows the lung cancer patient helps.

Leora Horn, MD, MSc, FRCPC: Do your pulmonologists see every patient who gets pneumonitis, or do you pick and choose? Do you manage it yourself? You’re at a big center. You’ve got multidisciplinary care. What should a doctor in the community do? Do you send every patient in, or should you see how you’re doing first?

Thomas E. Stinchcombe, MD: I generally try to manage it myself. If the patient is getting better, symptomatically, they stay in my clinic. If they’re not improving, like that patient, I send them to the pulmonologist and say, “Well, maybe it’s something I’m missing. Maybe it’s an infectious etiology that I’m not covering.” That’s when I send them. Generally, at 2 to 4 weeks without an improvement, I start to get nervous and try and get some more help.

Leora Horn, MD, MSc, FRCPC: Eddie, pneumonitis is not uncommon. If the patient does get pneumonitis, are you going to rechallenge them after that break from durvalumab?

Edward B. Garon, MD: It obviously depends on the grade. A high-grade pneumonitis is going to be of greater concern than a lower grade. Some of it’s also going to depend on a very subjective decision of whether I think this is radiation pneumonitis or not. The reality is that we’re often going to be spooked in these patients who have pneumonitis. We don’t have a great marker for pneumonitis. I generally use the same criteria that I would have used for restarting patients in the metastatic setting. Is it a low enough grade that I think it’s reasonable to add it back on afterwards, with the additional caveat that there are a subset of patients that will be cured? Maybe someone had a disease that might have been resectable, theoretically, but, for some reason, the decision was not to resect. Maybe the patient has a better prognosis. I might be less willing to restart or rechallenge with durvalumab in this setting versus in somebody who has bulky disease involving both supraclavicular lymph node stations as well as lymph nodes throughout the mediastinum. I have great confidence that this person is likely to progress. A rechallenge may make more sense in this setting.

Leora Horn, MD, MSc, FRCPC: Yes, you bring up a good point. We are going for cure in these patients and pneumonitis can be a fairly debilitating illness that can impact quality of life.

Transcript Edited for Clarity 
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Transcript: 

Leora Horn, MD, MSc, FRCPC: You brought up radiation pneumonitis. Radiation pneumonitis was low in that study. That was a nice surprise. Overall, pneumonitis was low in the study. We did not see a higher incidence. How are you sorting all of this out in patients who have pneumonitis? What is the culprit? Was it you, or was it your radiation oncology friend? How are you managing these patients? What are you doing?

Thomas E. Stinchcombe, MD: Something very important about the study is that the patients were enrolled after chemoradiation. I think the people who had significant toxicity were probably never enrolled on the PACIFIC trial. In the clinic, we see those people and we have to manage them. Generally, for people who we start on durvalumab and then they get pneumonitis, it can be very tricky to determine whether it’s the radiation or the durvalumab. This can be problematic. I did put 1 person on steroids. It turned out that she had pneumocystis pneumonia. And so, I think we have to be very vigilant and not just assume that it’s pneumonitis in this situation. These are new waters for us to tread in.

Leora Horn, MD, MSc, FRCPC: The patient probably didn’t get better on steroids, so that is something to think about it. But whether it’s immune radiation pneumonitis, they both respond to steroids. If they don’t get better, get your pulmonologist involved right away?

Thomas E. Stinchcombe, MD: I think an integrated system where the pulmonologist knows the lung cancer patient helps.

Leora Horn, MD, MSc, FRCPC: Do your pulmonologists see every patient who gets pneumonitis, or do you pick and choose? Do you manage it yourself? You’re at a big center. You’ve got multidisciplinary care. What should a doctor in the community do? Do you send every patient in, or should you see how you’re doing first?

Thomas E. Stinchcombe, MD: I generally try to manage it myself. If the patient is getting better, symptomatically, they stay in my clinic. If they’re not improving, like that patient, I send them to the pulmonologist and say, “Well, maybe it’s something I’m missing. Maybe it’s an infectious etiology that I’m not covering.” That’s when I send them. Generally, at 2 to 4 weeks without an improvement, I start to get nervous and try and get some more help.

Leora Horn, MD, MSc, FRCPC: Eddie, pneumonitis is not uncommon. If the patient does get pneumonitis, are you going to rechallenge them after that break from durvalumab?

Edward B. Garon, MD: It obviously depends on the grade. A high-grade pneumonitis is going to be of greater concern than a lower grade. Some of it’s also going to depend on a very subjective decision of whether I think this is radiation pneumonitis or not. The reality is that we’re often going to be spooked in these patients who have pneumonitis. We don’t have a great marker for pneumonitis. I generally use the same criteria that I would have used for restarting patients in the metastatic setting. Is it a low enough grade that I think it’s reasonable to add it back on afterwards, with the additional caveat that there are a subset of patients that will be cured? Maybe someone had a disease that might have been resectable, theoretically, but, for some reason, the decision was not to resect. Maybe the patient has a better prognosis. I might be less willing to restart or rechallenge with durvalumab in this setting versus in somebody who has bulky disease involving both supraclavicular lymph node stations as well as lymph nodes throughout the mediastinum. I have great confidence that this person is likely to progress. A rechallenge may make more sense in this setting.

Leora Horn, MD, MSc, FRCPC: Yes, you bring up a good point. We are going for cure in these patients and pneumonitis can be a fairly debilitating illness that can impact quality of life.

Transcript Edited for Clarity 
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